Will rethinking operations improve hospital outcomes?

An article in the New York Times (February 2, 2016) titled “Hospitals Focus on Doing No Harm”, describes the dramatic impact of operational changes on outcomes, with an eye to reducing the 75,000 preventable deaths nationwide. Orlando Health reports reducing patient infection related deaths by 44% with better procedures.   Minnesota Hospital Association reports reduction of pressure ulcers in patients confined to beds by 40% due to better coordination of care. Orlando Health reports a 32% decrease in blood clots in  patients in its seven hospitals by starting treatment for it faster when detected.  Should hospitals be held responsible for outcomes greater than the national average ? Should hospitals be held responsible for implementing state of the art treatment regimens ? In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

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41 Responses to Will rethinking operations improve hospital outcomes?

  1. Patrick Lee says:

    I worked in a hospital hematology laboratory. I observed many of my colleagues delaying sample processing–because only 1 or two samples existed on the table. Subject to this, I feel requiring better than national averages outcomes would force faster specimen processing and the generation of timely treatment decisions. Also, I agree that hospitals should be on the cutting edge of innovations–so hold them responsible for developing treatment regimens is worthwhile. Lastly, everyone responds to incentives–why wouldn’t a hospital not like being rewarded for sharing best practices ?

  2. Rodney Williams says:

    I believe the answer is yes to all three questions. It’s easy for employees to forget to wash their hands when there isn’t much emphasis being placed on it. However, when hospital staff know that cameras are installed that will ensure that proper hygiene measures are being taken and consequences for failure to comply, then I’m sure fewer people will forget to wash their hands. This is something that is completely within the power of hospital management to change also. I do think that it may be difficult for every hospital to identify steps in their processes that are in need of improvement and know how to implement necessary improvements, but if another hospital or organization, has already found success through a process change then it should be shared. This will allow other facilities to have a blueprint that may work for them also with few modifications. The overall goal is healthy patients leaving the hospital and not competition between hospitals. Keeping a successful processes secret will only led to unnecessary deaths that could have been prevented through information sharing. Hospitals that share info to help others should be rewarded because they are improving care beyond the walls of their facility.

    Lastly, hospitals should be held responsible for outcomes greater than the national average. In the article, it stated when surgeons were shown where they rank among others, they actually came forward requesting ideas for process improvements. I believe hospitals will behave in the same manner in which they would want to best the national average and would research and pursue processes that are likely to help them achieve that.

  3. Emily London says:

    *Should hospitals be held responsible for outcomes greater than the national average?

    Yes, hospitals that are not performing well should be known by the public. Their stats and reviews should be available online, like the way Yelp does for restaurants.

    *Should hospitals be held responsible for implementing state of the art treatment regimens?

    I think that depends on what they are trying to treat because regimens can change and I am sure it will be costly to implement a new regimen. For sure, any state of the art equipment or regimen that will aid in a life-threatening situation should be required by the hospital.

    *In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

    Yes, hospitals should be rewarded for having great operations. It would help with their reputation and they could gather more patients/customers from afar because of that. Whatever is working for their operations needs to be shared with others so each organization can learn from each other. The end result could be a larger percentage of lives saved.

  4. Frank Griffin says:

    Key points we should consider: 1) Institutions have been able to reduce health related deaths at hospital in the past. 2) Human life matters. 3) An institution of healing should not contribute to increased deaths. Car’s makers are held accountable for crash tests. Food and Drugs have to pass FDA approval. Why should hospitals be allowed to show increased hospital related deaths.
    Based on those points, I feel hospitals should be held responsible for implementing regimens that will reduce hospital related deaths. Possibly allow a timeframe for implementation. Also since the overall goal is to reduce deaths (since life matters), information sharing should be built into the process to expedite the implementation across the US.

  5. Paul C. Barron says:

    Q1: Should hospitals be held responsible for outcomes greater than the national average?
    I would offer that the national average is potentially too high. Instead hospitals should be differentiated by sufficiently funded and underfunded (an even split of the population). Then the standard of responsibility should be pegged at the outcome average of the underfunded hospitals nation-wide. Ultimately I do think hospitals should be held accountable, but not at the national average. I agree with Rodney regarding the sharing of best practices.

    Q2: Should hospitals be held responsible for implementing state of the art treatment regimens?
    Yes, if it is within their capacity and budget. Otherwise, to be held responsible would potentially force hospitals to expand their treatment offerings without expanding building capacity or their budgets. This would most likely result in a decrease in capacity for their current treatment offerings, a decrease in available funds for other treatments, and possibly a decrease in the “quality of service” the hospital provides to the patients it is already capable of treating.

    Q3: In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide?
    No, establishing a reward-based system for a hospital contributing to the best practices knowledge base could undermine the mindset that hospitals should share—that is caring for patients. It may seem unfair to expect hospitals to have such an elevated level of motivation and voluntarily contribute to the general welfare of patients nation-wide, but if a hospital community is unable to achieve this level of motivation (in the general sense), then that hospital has greater problems.

  6. Sooin Kim says:

    Reading the article, it seems that the basic Doing No Harm practices are not properly known to medical specialists. Surely, the best practices need to be shared so that these can be replicated many more with others.
    The trouble would be more on how to “implement” the best practices; whether a specific process need to be followed up via a detailed check list or not. Considering the importance of hospitals, one definitely needs to meet the minimum “absolute” criteria to be called a hospital. There are already multiple international and national regulations for these, and basic steps such as “Doing No Harm” should be part of these license conditions.
    However, I don’t think a hospital should be judged by the comparison with the national average. This relative evaluation may lead to distorted results than truly trying to focus on its chosen possible specialist areas, e.g. one may improve its evaluation rating by not taking difficult-to-cure disease- patients or terminal patients.

  7. Jimmy J. Guerrero says:

    I argue that using a national average as a measure of compliance, or success, for hospitals and medical institutions when providing healthcare services, does not necessarily encourages them to do “their best”. In fact, it may limit their ability to achieve their full potential by providing a “common” target level to aim at.
    Due to the fact that hospitals and medical institutions deal with human beings when at their most vulnerable state, I suggest that their focus should be, in addition to providing and maintaining state-of-the-art facilities and processes, knowing how to successfully deal with their patient’s emotional burden besides their physical ailments. It is a proven fact that highly capable and caring staff that can also deliver compassion and empathy, when needed, has a more powerful healing effect on patients than treatments alone.
    Should hospitals and medical institutions be held responsible for the outcome of their direct actions or activities? Absolutely! But at the same time, they should be supported, encouraged, and even incentivized, not just to reach a national average level, but to surpass it. If prospective rewards are linked to improvements in overall performance beyond the national average, when compared to previous evaluation(s), it may inspire continuous improvement efforts measured and judged mainly from a patient perspective.

  8. Akos Janza says:

    I am not 100% sure that rewarding everyone matching or exceeding the nation average will help, but choosing a benchmark and electing a goal is important. In his book The Checklist Manifesto Atul Gawande shows what the simple idea of the checklist reveals about the complexity of our lives and how we can deal with it. He brings up the example of hospitals and how checklist can help to reduce the number of preventable deaths. A simple surgical checklist introduced by the World Health Organization adopted in more than twenty countries as a standard for care and has been heralded as “the biggest clinical invention in thirty years” (The Independent). I argue that if such a simple checklist can save lives all around the world what could be implemented and how It could be enforced in the US.

  9. M. Moore says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Institutions should be required to measure and disclose their performance and be held responsible for their institutional outcomes via performance tiered reimbursement / Medicare /Medicaid payments.
    As part of competition and improving healthcare, Hospitals shall measure their performance based on a “Key Performance Indicators” and publish/display them. The public can make an informed decision when choosing their quality of care. In addition reimbursement levels the hospitals receive from the government should be tied to the institutional performance. If an institution performs well they would get a top tier reimbursement and if they do not perform the reimbursement levels would be at significantly reduced levels.
    This model has been successful with the implementation of “Door to Balloon time” for cardiology labs across the US to perform interventional procedures for a heart attack. As this measure became a standard KPI, the American Society of Cardiologist set targets for the time the patients entered the hospital to the time the intervention was performed (angioplasty balloon – arterial reperfusion) to continuously improve patient outcomes.

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    Hospitals utilize latest technology and state of the art treatment regimens to attract patients to their institutions via institutional marketing and physician referrals. Additionally these procedures and processes would directly influence their results to key performance indicators. Hospitals that compete and are successful will implement state of the art treatments.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide?
    Benchmarking and best practices should be proliferated and can be rewarded through publication rewards and/or mutual rewards via reimbursement levels.

  10. Erik Strobel says:

    Should hospitals be held responsible for outcomes greater than the national average? Hospital information related to patient outcomes should be easily accessible. The problem is that even if the information is available patients may have no other option for care in the area. Should we remove a doctors license to practice medicine? Malpractice insurance and hospital insurance rates could be tied to outcomes but at some point when we expect perfection we will have no doctors to treat patients.

    Should hospitals be held responsible for implementing state of the art treatment regimens? Who would you like to pay for these improvements my healthcare costs are already enough.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide? Yes it’s called consulting or takeovers/absorption into a network of hospitals.

  11. Ryan Laskey says:

    Should hospitals be held responsible for outcomes greater than the national average? Yes, hospitals should be required to post / market their performance against other health care facilities. If there was a standardized scorecard that would provide open sharing of information with their customers, then the market would be able to drive the necessary operational improvements.
    Should hospitals be held responsible for implementing state of the art treatment regimens? If hospitals don’t upgrade their treatments and their processes to meet industry benchmarks then they will lose their customers.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide? No, let the market drive their own improvements per the voice of the customer. There isn’t a need to regulate rewards. Communication can allow this to occur.

  12. LaBaron Hartfield says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Yes, hospitals should be held responsible for outcomes greater than the national average. This is an important measure seems to be indicative to the quality care patients receive throughout their hospitalization. Patients are likely to be attracted facilities that are known to offer better care.; Insurers are likely to be more willing to reimburse facilities that can reduce incidents outlined in the article at higher rate if they facilities can show the cost-savings in charges for customer care related to better treatment regimens..

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    My answer as potential patient in a hospital is yes. Everyone wants access to the best medical care and outcomes possible. However, I think healthcare providers should only be held to the requirements set forth by regulating agencies as the costs associated with implementing the most state of the art regimens could be cost-prohibitive for smaller or poor funded hospitals.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    There should not be a direct reward based on this measurement. Indirectly, hospitals can seek rewards by leveraging success to attract patients, recruit better medical staff and extract better reimbursement rates from insurers.

  13. Matthew Geddie says:

    Ryan Laskey makes a great point in a standardized system. Similar to national industries, allowing hospitals to “compete” against a standard that I believe should raise a certain rate every year would greatly benefit patients.

    Furthermore, perhaps implementing a federal reward system would motivate hospitals to compete on their treatment regimens, granting the top 10% additional funding towards research or other areas in which they seek funding.

  14. Peter says:

    In regards to the question “Should hospitals be held responsible for outcomes greater than the national average” I think the answer is yes, but I disagree with the group consensus on why and how. Standards set by medical professionals should placed on the hospital by States Boards of Health and vigorously enforced. All of the information disclosed in the reports should be public record and that will inevitably sway patient choice, creating a reward for well performing hospitals and an incentive for those who need improvement. This competition predominantly works in non-emergency cases and in a finite amount of distance (depending on the condition).
    I feel that setting up a Federally mandated reward system will create a moral hazard in the hospital enterprise. If a hospital is aiming for a certain score in a results based test, they could prefer to not take in certain patients. If a hospital system wants to have higher statistics, they may not offer services to impoverished or disenfranchised areas.
    While the desire for self-preservation will always insert monetary reward into health care (ie, people will give all of their money to make themselves, their loved one and sometimes even their pet, well) the institutionalization of mandated care, especially by non-medical professionals, far away from the location of care, creates competition to the creed of “Do no harm.”

  15. Michelle Hummel says:

    Should hospitals be held responsible for outcomes greater than the national average ?

    I believe hospitals should be held responsible for outcomes greater than average in their tier (not necessarily National average) and should be rewarded/recognized for these successes. Greater health outcomes can almost always be linked to more meticulous practice and better patient care. Hospitals should always be undergoing continuous improvement to achieve these goals, however, with a more standard approach to measuring these successes we can only assume better health outcomes overall.

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    My answer to this is only if applicable/available. Not every hospital has the funding/resources to be able to do this. If they are held responsible for such actions, the likelihood of short cuts and or short comings is high. Hospitals should have a standard approach to equipment functionality as well as treatment regimes, however, the specialist at particular locations are specialist for a reason. There are pros and cons to specialists vs. generalist as we discussed in class, and implementing state of the art treatment regimes at all hospitals would dramatically increase the cost of healthcare nationwide. While Hospital Administration and the State Department of Health and Human Services must implement a standard level of care, Hospitals should always be seeking continuous improvement to supersede these levels. I believe the responsibility lies within the Hospital tier itself and not necessarily within a National protocol.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

    More successful hospitals should share their successes with others *to help attempt to* improve outcomes system-wide; especially if these successes can be done with little to no cost. Obviously more expensive projects might not necessarily be able to be implemented and lower-funded facilities. Take the Hospital in the North East who decreased ER wait times significantly. Without remembering the specific facts, I believe the ER wait time went from 4 excessive hours to less than 30 minutes. With these vastly improve times not only did patient satisfaction increase but it attracted more “business.” Patients were more likely to chose this hospital due to their successes over others. These types of improvements, which may not be able to be heavily researched or re-engineered at other, lower-funded Hospitals, could be shared for the cost of nothing. I would be curious why anyone would say no?

  16. Mike Flatt says:

    Should hospitals be held responsible for outcomes greater than the national average ?

    I believe that yes they should be but there should be some established norms or industry agreed guidelines to adhere to as well. Although unlikely, there could be the potential for hospitals to collude and sand bag outcomes to make averages easier to achieve. Hospitals should be like most other businesses that are punished for poor performance.

    Should hospitals be held responsible for implementing state of the art treatment regimens?

    I feel that they should only be held responsible for this type of implementation when it is proven that these regimens will drive results to improve patient care. Terming a regimen as state of the art does not indicate whether it is useful or adds value. A small, rural hospital does not have the available resources to implement state of the art regimens that don’t drive results.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

    Hospitals should be rewarded for sharing best practices that decrease patient harm that they cause. They are businesses that need to earn a profit but I feel that they have an additional calling to serve the greater good of society. Serving the health needs of a population in the most efficient manner using best practices developed by others and spreading the wealth of knowledge is something that should be encouraged and rewarded. The more difficult question that I’m not sure I have an answer to is how to fund this and how to allocate those rewards.

  17. Hospitals should be responsible say when the outcomes are greater than ~5% (for urban) to ~10% (for rural) of national average. It may pose a financial challenge and need for training staff for hospitals to implement state of the art treatment regimens. So I think they should be given a specific time frame within which they need to have the state of art facilities and then have them held responsible. For mutual benefit, it is important for hospitals to share their success, otherwise they may find themselves not being successful in other operations.

  18. Dan Skinner says:

    Should hospitals be held responsible for outcomes greater than the national average? No. You cannot penalize every hospital that is below who has outcomes below the mean and expect to improve outcomes. You could set a target that hospitals have to meet, but if the target is moving as the average moves, you can only improve your outcomes so far. Once you reach that level you encourage cheating, similar to the cheating (by teachers) you see on standardized tests. You can specify that hospitals improve to reach a certain target, but the target has to be realistic, attainable, and not floating to be effective in the long run.

    Should hospitals be held responsible for implementing state of the art treatment regimens? Hospitals should be required to have limited equipment. Beyond what every hospital needs hospitals should be allowed to use their budgets to specialize. Would you require every hospital to have advanced equipment, even if they do not have the expertise on staff to use it? What kind of equipment is necessary? What best practices are necessary? Where is the line drawn, and who draws it?
    I think hospitals should be rewarded to encourage them to share their best practices with their neighbors, but you cannot force the neighbors to adapt the best practices. I think the most effective rewards system would be the advertisement of outcomes like those above, and comparing them to their direct competition.

  19. Courtney Metzger says:

    Should hospitals be held responsible for outcomes greater than the national average?

    Yes, I believe they should be held accountable for outcomes greater than the national average. There should be strong metrics in place and they should be transparent to the public. This would allow for better information and ultimately better decisions for the patient. High performing hospitals would benefit and low performers would be forced to improve.

    Should hospitals be held responsible for implementing state of the art treatment regimens?

    As a whole, yes I believe they should. However, there must be some consideration for how this is regulated. All hospitals should not require all treatment types. Diversification should be allowed as it will benefit the patient and the hospital.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?

    In keeping with the spirit of allowing the market to provide reward, I have to say no. However, I do see value in providing a program or platform to encourage knowledge share.

  20. Sandra Aldana says:

    I am coming from a country that provides universal health, so I am a bit terrified to think of a hospital as a business and not a place that restores people’s health. That said, while hospitals should attempt to reach the maximum quality possible, I am not sure whether it is possible and how much that tracking and enforcing would cost that could be invested back in better care.

    Hospitals should be encouraged to share best practices with one another. We need to remember that a patient does not always have the choice to go to a hospital. In many cases it is chosen for them (like in a car accident). ANYBODY could end up in one, and it is a pity that someone dies or simply because a hospital did not share information with another. If a business like Patagonia shares its best practices with its main competitors and still be profitable, why should hospital be different? What better reward than saving a life or giving someone back their health?

  21. Oswin Joseph says:

    I think the question is how can we reward hospitals that have outcomes better than the National Average. In order to do that, there has to be common scorecard as Ryan Laskey mentioned to measure a whole range of metrics including preventable deaths, patient infections, blood clots, pressure ulcers etc. Hospitals can be graded on a scale like restaurants or universities. If a hospital is lower on the scale, they will lose customers and revenue which will force them to improve by implementing state of the art technology, driving efficiencies etc. Yes successful hospitals should be incentivized to improve other systems – though the question is how to reward good hospitals.

  22. C. Thomas says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Many have already commented on the fact that a scorecard should exist that measures hospital performance. Some may not know that this actually already exists on many different levels. For example, the Joint Commission (organization that provides accreditation for U.S. hospitals) publishes national hospital inpatient quality measures (http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx). The problem with this is that healthcare literacy is extremely low in the U.S. While many patients may not know such measures exist, even more will not understand them or know how to use them to their benefit, and many more will not have access to them due to low socioeconomic status. I think the real question should be something like, “how can we make care in U.S. hospitals more transparent and more user-friendly to the average American that does not have formal training in healthcare.” Ultimately, yes, I believe that hospitals should be held accountable for certain preventable outcomes, but not ANY outcome greater than the national average. Many outcomes such as deep venous thrombosis after surgery, central line infections, and pressure ulcers are 100% preventable. It takes a leadership team to realize that focusing on their staff as a priority is the key to making this happen.

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    I think this is a loaded question and ultimately my answer is no. State of the art does not always mean it will provide the best possible care for the best value. Many times providers order unneeded medications, tests, and procedures that are “state of the art” just because they can rather than if they should. This culture of the practice of medicine in the U.S. is a big reason why our healthcare system is in such disarray. I believe that institutions should not only be implementing state of the art treatment regimens (not required to do so though) while at the same time focusing on providing the best possible care for the lowest cost. It is often the case that more expensive, state of the art treatment regimens will only result in a marginal improvement and often times no improvement at all in the quality of care. U.S. institutions should be spending their healthcare dollars more wisely, because often the easiest thing to do to improve hospital outcomes is as simple, and as inexpensive, as washing your hands.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    Absolutely! But I think this actually already happens to a certain extent when innovators publish their results in medical journals. This brings prestige to the author(s) and to the institution which also brings them financial benefits as well. I actually think that more emphasis should be placed on publishing negative results of research as well, which has been revolutionized by The Journal of Negative Results in Biomedicine. Negative results in research are far too difficult to get published and ultimately result in inefficiency of research in the entire field of medicine.

  23. Meera Gursahaney says:

    Public hospitals should be held to standard practice. Ideally, competition between private hospitals is continuously driving innovation to increase the standard of all hospitals. the same goes for the implementation of state of the art treatments; it seems unreasonable to expect public hospitals to be on the cutting edge, but as what was once “cutting edge” becomes the standard, it is the responsibility of all hospitals to ensure they do not fall behind. I really liked Emily’s idea of the “Yelp for hospitals”, this ensures patients/consumers are able to to make decisions that drive competition, advancement and innovation in the medical field. there should certainly be incentives for hospitals to share proprietary information in the name of saving lives. By sharing that information a hospital is losing out on the value of being the sole proprietors of that technology which would decrease the incentive of a hospital to sink money into R&D if there was not a financial benefit. A reward for sharing such information would allow for an increase in the greater public health as well as provide and incentive for hospitals to continue doing the expensive research necessary for such innovation.

  24. Aaron Wheadon says:

    I agree that hospitals should be held responsible for achieving better results than the national average. I do believe we as consumers should look to them to do their best for us in the communities they serve (and in which we live!). As part of that expectation, I do feel they should be looking at, researching, and implementing proven state of the art treatments that will increase the quality of life. And as they improve their service and level of care, their is a part of me that feels that the wealth of knowledge should be shared, especially in smaller or more rural communities where resources are scarce. But also large metro centers, where efficiencies in operations may lead to faster service and better care. Their is however, another part of me that wonders about hospitals and their competitive environment. If the knowledge is shared, does a hospital lose its competitive advantage, potentially decreasing its revenue stream?

  25. Nicholas Vandal says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Yes, I do believe hospitals should be held responsible for outcomes greater than the average, after all it is their job and part of the Hippocratic Oath that physicians take. If they know that there are ways to decrease patient infections, ulcers, blood clots, etc it is not only the physicians and hospitals responsibility but also their duty to improve the operations and they need to be held accountable for treatments that are not up to par.
    Should hospitals be held responsible for implementing state of the art treatment regimens?
    I don’t believe so, each hospital may have different specialties, treatments, etc. Updating to each new state of the art treatment may be very costly which would be passed on to the patient to the point where the patient may not even seek treatment for the ailment which could have been treated with something much less costly and more simple solution that didn’t require “state of the art” regimens. It seems to be more of a marketing ploy than anything for a hospital.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    Yes absolutely! Doing this should be rewarded and not doing this should be punished. Putting profits over lives by keeping a successful operation to oneself is pretty sad. Plus if they share their operational success they can make a nice marketing campaign out of it and most likely increase patient intake, effectively increasing profits anyways.

  26. Steven Jones says:

    I thoroughly enjoyed reading all the previous comments. There is certainly a large consensus that hospitals have a shared stake in social welfare – there seems to be low tolerance for a divergent model. Additionally, as some people referenced class discussion on the topic, it seems as though they were further along in the class than we are.
    As for my answer, I want to ride off C. Thomas’ answers as there was a certain insight that I find intriguing.
    Should hospitals be responsible for outcomes greater than the national average?
    Considering U.S. federal and state governing bodies have created regulations around physician and hospital care as an extension of the people’s will to make hospitals the primary source of health intervention, as C. Thomas wrote, hospitals should be held accountable for certain preventable outcomes. However, being accountable for any outcome greater than the national average is undesirably restrictive to certain hospitals, mainly the rural and/or underfunded ones. Consider a hospital that is already underfunded, maybe rural or barely suburban-close to rural, where the distance to the next hospital is prohibitive for travel for urgent or emergency care. Consider that the hospital is performing well enough that there are no infection-related patient deaths, but there is below national average performance for readmittance. However, more often than not, the hospital remediates the issues that cause readmittance, again, at a rate below the national average. Now assume this hospital suffers from diseconomies of scale at times in order to provide enough resources to service stochastic demand. Couple that with the fact they want to provide state of the art treatment regiments at value. The question becomes, how many seasons can they afford to perform well, but not well enough to beat the national average before the financial death spiral sinks in? Choosing what is reported and measured against the national average is really where the rubber meets the road. As C. Thomas wrote, much of what can be done to curtail certain preventable outcomes is attainable for any hospital in any class such as measures to ensure hand washing is done or that medication reconciliation is encultured in the community and is performed by the hospital.
    One small note on reporting. As a former public school educator, I understand Dan Skinner who wrote, targeting hospitals which underperform against moving targets, which national averages would tend to move, leads to gaming the tests much like educators have done with No Child Left Behind tests. It wouldn’t lead to better performing hospitals, in reality, just better reporting hospitals. Additionally, Certain targets should be used to hold hospitals accountable as a measure for analysis sake, but choosing those targets should conform to regularly available resources to hospitals in classes of hospitals (urban, suburban, major metropolitan, rural, fully funded, underfunded, etc..),
    Should hospitals be held responsible for implementing state of the art treatment regimens?
    Again, C. Thomas wrote about the inherent conflict between state of the art treatment regimens and necessity. There are more than a few cases of overcharging for care because unnecessary procedures or tests are run, or ambulatory care is avoided when it could have been a sufficient level of care. Often Physicians are reluctant to sustain a type 2 error, or pronounce a sick person well, while they tolerate a type 1 error, or pronounce a well person sick. This happens because reward systems and our highly litigious society favors type 1 errors to type 2 errors. There is a healthy fear in American society for iatrogenic illnesses. This is partly what causes sky-rocketing health care costs. So, when demand for state of the art treatment machines increases, the cost increases, and that cost is passed onto patients. This is a serious issue in our society. Therefore, a balanced approach must be instituted where value can be found, where state of the art regimens are utilized, but at a cost efficient level. If there is an external accountability for hospitals to implement state of the art regimens regardless of other factors, then costs will become so cost prohibitive that people will either avoid the hospital when they need to go, or an upheaval to the system will occur. There are no guarantees that an upheaval to the system in the American culture (actually, in the very diverse American culture), would go well and produce a stable and equitable system. Deeply seated opinions on the subject are separated by a huge gap – and that gap is evergrowing.
    Should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    Absolutely – that is, if the reward is just positive with no negative rewards. I believe one of the first posters wrote that she worked in a lab where a technician had only 1 sample so didn’t test it. However, what if other hospital samples could be pooled and tested together? That would create a synergy among participating hospitals that could advance care techniques and services.

  27. Jesse Kiste says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Yes, by holding them lower than the national average, hopefully it will drive the average down (or the lowest performing hospitals out of business). I also think that information should be readily available for the consumer to make an educated decision. The consumers alone could hold hospitals accountable by selecting the better hospitals (if the data is provided). Should the doctors also be held responsible?
    Should hospitals be held responsible for implementing state of the art treatment regimens?
    This is a tough one, I feel that if there is a proven best practice, a hospital shouldn’t be allowed to use an inferior method (exceptions for extreme cases). At the same point if hospitals are investigating clinical methods, they should be given the freedom otherwise we are stiffling innovation.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    Yes, getting rewarded for sharing best practice will only elevate the care (and reduce death) that all hostipals can provide. It might also drive healthy competition for innovative practices.

  28. Beth Hinchee says:

    I don’t believe hospitals should be held responsible for outcomes greater than the national average. The expense to maintain capabilities to attain that level of performance would greatly increase costs for all medical care, which in turn will mean fewer people will be able to afford to get the care they need. The same argument holds true for implementing state of the art treatment regimens. You may need facilities in each region with advanced treatment capabilities, but it doesn’t make economic sense to drive that out to every hospital. On the other hand, successful hospital operations should be rewarded for sharing their successes to improve outcomes in other facilities. Each hospital can then judge their capability to implement best practices and do so accordingly. Both hospitals and patients could benefit from that approach.

  29. Alyssa Bybee says:

    I disagree on the first two counts. While I do agree with many of you regarding the social responsibility of hospitals to administer best care practices and strive to obtain superior performances, Beth is absolutely right that the expense involved in implementing many of the newest and best technologies, staffing, treatment, facility improvements, etc. is not an economically sound or cost effective decision for EVERY hospital to pursue. As we learned in our Organization Behavior course, it is unreasonable and ineffective to expect a positive progression when so many distinctive differences and (corporate) motivation will exist between each facility depending on its geographic location, resource availability, population, etc. And besides, shouldn’t healthcare be a patient-care focus rather than competitive focus? Allowing each facility to individually analyze its strengths and weaknesses, and what factors are influencing both, an opportunity exists to create the BEST hospital for that area and for that population utilizing it, regardless of the national standards, ultimately improving patient care, which is the goal.
    I do agree that by rewarding stellar practices from hospitals and offering merit incentives, this will encourage other facilities to invest in research and resources that they otherwise may not have considered or taken the time to evaluate within their own organization.

  30. Sarah C says:

    Healthcare professions should be held accountable for their actions which lead to outcomes greater than the national average so that these cases can be looked at and investigated. By accountable I do not necessarily mean ‘punished’ in some way, but an explanation and investigation required. In some areas/ specialities due to population demographics it is inevitable that there will be higher cases of certain issues, and thus explainable above average outcomes.
    Implementation of ‘state of the art’ treatment regimes – this is interesting. I know that a lot of people will think that purchasing the latest technology will help to solve a lot of issues. I would suggest that whilst investment in technology is obviously required this should not superceed the treatments which are proven and work well. One must also understand that you can buy all the technology you like, but if you do not have a workforce which understands how to use it/ interpret the results it provides/ is confident in their abilities with the tech. then it becomes worthless. Investing in technology must also go hand-in-hand with investing in the workforce and their skills.
    It should be standard for healthcare professionals to share good practice not only with their direct colleagues, but also within their Hospital/ Clinical areas but also nationally and further afield. By working together and sharing good ways of working people can be treated quicker, with less wasted resources and therefore cost less to treat. There should not be a reward for sharing insight and best practice – people who work in healthcare are there to help people (one would hope) and therefore a reward should not been required.
    I believe one of the major hindrances of healthcare globally is something which costs nothing; communication. Clear, concise and speedy communication is essential for providing an efficient, safe service but it is something which fails often.

  31. Bradley Wensel says:

    Should hospitals be held responsible for outcomes greater than the national average?
    – Hospitals should be held to an outcome target that is set by national benchmarks, but one national metric will not work. A standard outcome metric without being risk adjusted for the type of population of that hospital serves would not be achievable in most cases or impactful. The patient mix of a hospital is not the same across each city, state or country. We need community hospitals to serve most general medicine needs, and we need large level one trauma centers and academic and research centers to be able to continue to push innovation in medicine, but outcome metrics can’t be the same. It is in the interest of the patient to have hospitals that are experts in more advanced procedures and clinical testing, which is good for patients and the future of population health, but hospitals can’t be all held to the same metric or no hospital will be incentivized to do the tough procedure or serve sickest patient. Currently, value-based care efforts being led by CMS (Centers for Medicare and Medicaid Services) are tying reimbursement to the quality of care provided and rewards providers for both efficiency and effectiveness. These efforts led by CMS are the first step in setting metrics in place that only benefit the patient, but tie performance to reimbursement and in the end should drive down the cost of care in the United States. However, these metrics are not standard across the board and don’t set just one target outcome.
    Should hospitals be held responsible for implementation state of the art treatment regimens?
    – Hospitals operate on very low margins usually 10% or less, which makes continued investment especially in today’s fast innovation cycle very difficult. With hospitals not 100% funded by the government in the US, it is hard to mandate implementation of start of the art treatment regimens. However, hospitals should be incentivized by insurance and government funds to invest in proven treatments that improve outcomes. A change in how hospitals get paid and incentives could help advance key centers of excellence across the country to take on more investment on proven treatments and technologies. Lastly, it should be understood that it isn’t efficient for every hospital to offer the same services. implementation of state-of-the-art treatment regimens should be limited to not drive up the cost of healthcare for hospitals offering something that isn’t needed across every facility, and possible incentives could be tied to hospitals that exceed the expected outcome metrics set for their population served.
    In addition, should more successful hospital operations be rewards for sharing their successes with others, to improve outcomes systemwide?
    – Yes, I think there needs to be more sharing across hospitals and rewards, but the question is who funds such rewards. With the M&A activity in healthcare the last few years it can be said that this is happening on a more regular basis within a regional system than what existed just 10-15 years ago. However, incentives for such an operation are today being built by health system innovation centers developing products and technics, which are commercializing them to other systems, which is a great revenue stream for many, but not paid for by the consumer/insurance provider.

  32. Enoch Obeto says:

    Should hospitals be held responsible for outcomes greater than national averages?
    – Hospitals should be held responsible for outcomes in general, and measurement geared towards certain criteria like demographics, year over year performance, hospital type, procedures etc and not on a national average. This is similar to the debate in the US about high school education, where some have argued that high schools should be measured solely on their performance in national standardized tests without taking into consideration the uniqueness of the different communities where the schools are located or the year over year improvement in a particular school district.
    Should hospitals be held responsible for implementing state of the art treatment regimens?
    – There should be standardized minimum base line for test and treatment procedures, and this should form the bases for hospital certifications. However, hospitals should have the freedom to decide on how much state of the art treatment regimen beyond the required baseline they adopt. Hospitals generally don’t have the same level of profitability, so a requirement like this may put undue pressure on less profitable hospitals.
    Should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide?
    – Yes, this will have a positive impact on hospitals in general and help drive improvements. Healthcare service delivery as in many other critical life saving services rest heavily on collaboration and exchange of knowledge and data across different platforms. Hospitals will be greatly encouraged to do this if they receive compensation and the net effect is better outcomes for patients.

  33. Christian Kersten says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Yes, hospitals should be held responsible for outcomes in general. You should also be able to see reviews and statistics online (like “jameda” for doctors in Germany), to get a better understanding of a hospital’s performance. Additionally they should measure certain KPIs and report the changes within certain periods.
    Should hospitals be held responsible for implementing state if the art treatment regimens?
    It be implemented a quality assurance to have a certain standard. State of the art treatment is nice and absolutely desirable for customers, but on the other hand very costly and maybe non-economic. Therefore I’d say it depends on the individual case but I would implement a “state-driven” minimum standard / quality gate to ensure that certain quality standards are met.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    Definitely! Sharing best practices and knowledge is a huge success factor and can bring massive improvements. Although hospitals are economically competing with each other, sharing best practices should be incentivised to lift up the overall quality.

  34. Alan Cottrill says:

    >>Should hospitals be held responsible for outcomes greater than the national average ?
    From my perspective I don’t think we can hold hospitals responsible to outcomes greater then a national average and in reality the outcomes each hospital can achieve are certainly going to be a related to their funding and level and quality of assets .. both human and fixed. As others have commented; not all hospitals receive or have equal values of these. Brad and Enoch’s comments regarding uniqueness of communities and national standards are very relevant when we try hold hospitals to standard levels and measure their “success” as an institution.
    >> Should hospitals be held responsible for implementing state of the art treatment regimens ?
    I don’t believe that we have either the ability to impose the implementation of “state of the art treatment regimens” without funding those institutions for such capital investments as are necessary to be able to offer them. Accordingly it would seem to be a better allocation of capital to increase basic level hospital services and thereby improve performance for more common typical outcomes at all hospitals but helping to provide access on a more broader regional or geographic basis for “state of the art treatment regimens” as not all facilities have the funding, equipment and assets needed to provide those specialized services.
    >> In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    Absolutely the sharing of knowledge and data to help improve outcomes systemwide should be encouraged and rewarded. However the process of doing that, sharing knowledge and information, is certainly not a simple task given and funding for the work and cost of such knowledge sharing should be part of the reward so that hospitals, already often underfunded, are not taking from other resources to do this.

  35. Jessica Heaton says:

    Should hospitals be held responsible for outcomes greater than the national average ?
    – I think they should be held responsible, but as mentioned by Brad in order to successfully implement, there would need to be several metrics that are used to tell the full picture. And as Alyssa mentioned, these metrics would need to be thoroughly reviewed to ensure the metrics and consequently rewards/punishments would drive appropriate behaviors. For example, if we only measured by speed of procedure or number of patients, that may not be in line with the goal of quality healthcare, which I’m sure would not be acceptable to compromise. And, I would caution against penalize/reward hospitals based on solely point in time numbers, but would look to see where trends are showing potentially low performing hospitals. Overall while beneficial, it would be a costly initiative to implement, so the first major challenge would be how this would be paid for and who would be responsible for the oversight across the industry?
    Should hospitals be held responsible for implementing state of the art treatment regimens ?
    – I do not feel hospitals should be held responsible for implementing state of the art treatment. “State of the art” is such a fluid idea, especially with the constant innovation and improvements with technology. This would be challenging to maintain that level of innovation, as well as how would this be measurable across hospitals. The term “state of the art” treatment is extremely subjective, and while all hospitals should strive to provide the best care for their patients, each hospital may have a different client base or need that is better for them to specialize “state of the art” in a segment of treatments versus across the board.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    – Absolutely, while Hospitals are still at the end of the day a business, many times based on geographic location there is little direct competition with peer hospitals. Sharing information and best practices across the board would hopefully increase efficiencies and yield better results for them and ultimately all customers.

  36. Sandeep Singhatia says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Yes, if the national scorecard/average numbers can help provide better services; but I guess someone must watch the data how a hospital reached there. We all know hospitals can hide medical errors mainly those who are big in market, they don’t want to loose their brand/reputation to look good ethically. On the other side even in a good hospital with competent staff too many things can go wrong;
    Should hospitals be held responsible for implementing state of the art treatment regimens?
    A structured treatment plan in a hospital is designed to improve and maintain health; and I believe hospitals are following best treatment plans from past practices. For sure hospitals should be able to provide standard level care ( depending on type of hospital it is e.g. ICU, Trauma center, primary care etc) and they should be held responsible for it but expecting every level/type of treatment from each and every hospital is not possible. There are many factor to consider like funding availability to hospitals to implement “state of art treatment”, feasibility, patient requirements in the area, geographical area etc. e.g. a small, rural hospital does not have the available resources to implement state of the art regimens that don’t drive results.(mentioned by Mike Flatt)
    Should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    Recognizing and rewarding someone’s effort is always been a key factor of motivation and here we are talking about people who are saving millions of lives everyday, so Yes successful hospital operations should be rewarded for sharing their successes with others. Rewards will help improve the Brand/Reputation (and they can make more money) but it will encourage hospitals to look at the opportunity of learning from each other’s best practices. Ethically it sounds great but Important question is in this world of competition and making more money why any hospital would like to do it? I believe there has to be a authority/group/policies/rewards/incentives which can encourage hospitals to focus in this direction (concept of sharing).

  37. Henry Reed-Schertz says:

    Should hospitals be held responsible for outcomes greater than the national average?
    I believe that hospitals have a moral and social responsibility provide the best care and must own the actions and outcomes provided by their facility. As Jessica, Brad and many others have mentioned, streamlining the expectations on a natal level can easily jeopardize the quality of care and create inefficiencies as hospitals without the capacity try to adhere to theses national averages that can leave unreachable numbers for a hospital that does not have that capacity. I believe we should be promoting hospitals to provide quality care and focus on creating and adaptable environment for doctors and nurses to provide the best service and care to their patients.
    Should hospitals be held responsible for implementing state of the art treatment regimens?
    I personally believe that innovation and growth within the healthcare industry are absolutely necessary, again, it’s unreasonable to put these pressures on all hospitals. Rather, focusing on distinctive treatment facilities and allowing hospitals the freedom to assess and treat the ailments that are affecting their particular geographic region, an opportunity exists to elevate quality of care. Also, I really appreciate and agree with Jessica’s comment that it would be nearly impossible to stay up-to-date, from a cost standpoint, at the rate at which technology is improving, without sacrificing elsewhere.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    Sharing best practices and knowledge across a network can only benefit the end use or the patient but must only be implemented if it fits that hospital system. While each hospital can have a central focus and can be rewarded for sharing focus it cannot be expected to blanket implement these actions. As previously mentioned allowing hospitals to focus on their particular expertise should only benefit the community and the health care professionals that work there. Each hospital needs its own freedom of choice to take all the best practices and do what works best for them. While national standards ay always set a bench mark theses hospitals need to be reviewed on an individual basis.

  38. Marcello Sanzi says:

    1) Should hospitals be held responsible for outcomes greater than the national average?
    Yes, distinguishing differences in quality of care across providers requires precision in both the design of the outcome measure and the actual recording of all the measure’s elements and good medical care leads to improvement in the outcome within the time period for the measure. High value in health care is a great outcome that matters to the patient and implementing a value-based strategy is on the mind of nearly every health care organization in the U.S.
    2) Should hospitals be held responsible for implementing state of the art treatment regimens?
    Yes, since state-of-the-art technology leads to more precise diagnosis and better treatments allowing physicians to detect tumors earlier, target cancer cells more precisely and perform complex procedures using minimally invasive techniques.
    3) In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    Yes, by sharing their successes with others they improve outcomes systemwide and according to one of the recommendations of the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001b: 6): “All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.”

  39. Linda Sverdrup says:

    Interesting Questions! First, Hospitals should not be compared to any other institution but other healthcare provider and hospitals in term of statistics. Should hospitals be held responsible for outcomes greater than the national average? My question: what are the national averages and where did this number come from? Doctors take a Hippocratic Oath to swear to uphold specific ethical standards. Unfortunately, hospital administrators and healthcare insurance companies do not. That is the most important delima facing healthcare today. The processes enforced by insurance companies cause a waste of doctors’ time, which takes away from patient care and often dictate patient care. Unbelievable, right?!! The ultimate goal of any hospital should always be Quality Healthcare, Innovation to improve outcomes, create more satisfied patients, and better value of care for the patient. Most would want and seek to better than the national average in their specific fields.
    Should hospitals be held responsible for implementing state of the art treatment regimens? Our hearts & minds say yes to this question! However, if insurance companies limit the value of a procedure – how would a hospital ever be able to recoup costs of new innovative procedures? In fact most of these innovative procedures are often denied by insurance companies. That means hospitals take a loss. Who wants that? Unless a rich actor/actress, business man/woman, or philanthropist donates money or needs the procedure, the struggle for these innovative procedures to become a “standard procedure” is very difficult. Or the cost is left on the research companies which delays and disincentivizes innovation. The United States populace needs to ensure their representatives understand this constraint on healthcare. Government policies and legislation should conform to the principles the US citizens want, need and vote for. Miracles don’t happen on their own.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide? Definitely YES! As a six sigma black belt, process improvement is a continual process. Employee turnover, new innovations, variation in training, variation in education, stress levels, employee health, communication, new diseases, etc. and more all contribute to deviations in processes and healthcare. Rewarding those on top, as well as incentivizing “sharing” processes and policies that focus on quality care is critical to ensure the national average remains at a reasonable level of quality care. I don’t want my healthcare based on a bell curve! I want my care in the 99 percentile.

  40. Lindsey Minto says:

    – Should hospitals be held responsible for outcomes greater than the national average ?
    A: Severly underperforming hospitals should, at a minimum be held to outcomes equal to the national average. Getting that far would be a great increase in the level of care for patients across the country. It is unreasonable to expect all hospitals, such as rural care centers and hospitals serving impoverished regions, to be better than the national average. There should be an agreed upon level of standard care that all can reasonably achieve to elevate the level of care.
    – Should hospitals be held responsible for implementing state of the art treatment regimens ?
    A: State of the art treatments are great. That is what pays my paycheck. However, there are certain technologies that are considered state of the art but have failed to prove their economic value. A current hotly debated state of the art treatment is a robot for spine surgery. These are big expensive pieces of equipment that not every hospital can afford and that don’t span multiple fields of medicine. So if every hospital is expected to be to that level, we will further exacerbate the health care cost issue in this country. We should instead focus on buying only technologies with strong economic arguments and proven success and cost savings.
    -In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    A: Hospitals should be incentivized to do research on improving operations and patient care standards. From there, there should be easily accessible data that is available to all healthcare providers and executives. If incentives for the researching hospitals are needed to encourage content creation, strategic initiatives should be funded to best channel the research to the most needed areas.

  41. Vivek Chakrabortty says:

    Yes, hospitals should be held responsible for their outcomes by the community they serve. The national average may not represent the needs of individuals communities. Therefore, the outcomes should be defined by the community based on its unique healthcare profile and requirements. Implementing state of the art treatment regimens is ultimately determined by the community being served and the investment they make locally to incentivize the hospitals’ behavior. A hospital that is antiquated in its regimens will be replaced by competition if the community creates the appropriate environment. In addition, sharing best practices and successes are already an integral part of practicing medicine. Hospital operations will be rewarded for adopting successes of others and improving their own outcomes.

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